Medical note by a non-medic: CRP Conundrum

Medical note by a non-medic: CRP Conundrum

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M Zahidul Haque
CRP or C-reactive protein is a protein produced by the liver in response to inflammation. The level of CRP rises when some inflammations are there in the body. Inflammation generates when the body is attacked by bacteria, virus, fungus or any other irritants. Inflammation itself is not an infection; rather inflammation acts as a defensive mechanism against infection and helps in healing body’s infection. It is actually body’s immune response. Often longtime inflammation causes chronic inflammatory diseases.
The C-reactive protein or CRP is one of the markers of infection in the body. CRP-test is done to measure the CRP level in the blood. The normal range of CRP is less than 1.0 milligram per deciliter (mg/dl) or less than 10 milligrams per liter (mg/L). CRP test result showing more than 3.0 mg/L is considered as high risk level. There is high-sensitivity C-reactive protein (hs-CRP test to determining a person’s risk for heart disease). However, the common test for detecting body’s inflammation is ESR (Erythrocytes sedimentation rate). The CRP increases quickly and decreases rapidly (on treatment) than ESR.Now let us see how CRP test results of different diagnostic labs put me in confusion. The CRP test was done on my younger sister who has been suffering from continuous and acute pain on her lumbar spine area plus both lower limbs for the last 4-5 years.
A few years back when she was attacked by severe spine pain radiating to legs, we consulted with a number of orthopedic, neurosurgeons, pain management specialists, and medicine doctors. A lot of medicines were administered upon her including epidural injection but with no significant improvement. At last, Neurosurgeon Dr. Syed Sayed Ahmed, Director, Neuro Center, United Hospital,Dhaka had performed surgery on her lumbar spine. But her pain was not reduced rather severe infection was detected around her surgery area. Her CRP level was raised to 54 mg/L. Injection Meropenem plus Vancomycin was immediately started to control infection. After some days she was discharged from the hospital with a cannula on her hand because Dr. Ahmed wanted to continue the Meropenem injection for some more days. Appreciating the issue rather critical, I decided to take advice from some experienced physicians in the line known to us. I took her to Prof. Dr. Zillur Rahman, a prominent Neurosurgeon of the country who immediately removed her cannula on the consideration that it is not wise to continue the IV antibiotic injection for a long time without knowing the actual cause of her pain. Of course her CRP level was then come down to normal.
Let us get back to her pain and CRP issue. In fact, even after so many types of treatment, her spine pain continues to persist. Several MRI, X-rays, CT-Scans including some cardio examinations, liver and kidney functional tests were done to locate the actual point of pain. She has been taking semi opioids preparation (Trmadol+ Paracetamol) for the last two years because the NSAD drugs would not work on her.
She was under regular haematological monitoring. A recent blood test found a higher level of CRP. It was in the high risk level, i.e. 96 mg/L (Popular Diagnostic Lab. 21/09/2016). Having seen this CRP test result, some doctors suspected some acute infection in the body (probably on the surgery area). Some suggested to get admitted in the hospital and to strat Meropenem injection. Meropenem is an immune suppressive antibiotic and decreases body’s defensive mechanism. Last time when Meropenem injection was administered upon her, the WBC was dropped to an alarming level and she had to be given Nupogen injection plus blood transfusion. I contacted with Dr.Md. Alumuzzaman Joarder, Consultant Neurosurgery who is a very nice and helpful doctor. He advised me to repeat the CRP Test. Interestingly, the CRP test done on 22/09/2016 at Dhaka Apollo showed a different result, much lower than Popular—5.76 mg/dl (57.6.mg/L)—only within one night the difference in reading was 38.4!
The above CRP results created confusion. True, the CRP decreases rapidly but which result was correct? Meanwhile, in June 2016 she was operated for the 3rd time at Artemis Hospital, Gurgaon, India. With the help Ms. Annu Puri and Dr. Ruchika Malhotra of Indicure, India I got her case reviewed by a number of reputed Orthopedic, Neuro and Spine Surgeons in India. Majority including internationally reputed Spine Surgeon Dr. Hitesh Garg of Artemis Hospital suggested a spine fusion surgery. It may be mentioned here two very skilled and efficient doctors, Col. Dr. M Al Amin Salek Neurosurgeon of the United Hospital and Dr. Amit Kapoor Spine Surgeon of Apollo Hospital, Dhaka had earlier suggested spine fusion surgery. But due to the previous odd experiences, our close ones did not approve doing the 3rd surgery here. Anyway, Dr. Hitesh Garg and his team including Dr. Saurabh Rawal had successfully done her spine fusion surgery at Artemis Hospital. The surgery yielded some positive results which include some reduction in spine pain. But the pain spread to both lower limbs.
Anyway I contacted with Dr. Hitesh and informed him about the confusing CRP test results. He firmly advised me not to give any antibiotic but to come to their facility for a thorough check-up. Accordingly we went to Delhi on 4th October. Dr. Hitesh immediately ordered some tests including CRP, MRI, NCV/EMG etc. Interestingly, the CRP test (dt. 05/10/2016) result came within the normal range, that is, 0.6 mg/dl (6 mg/L). Still to get the issue clear and confirmed, Dr. Hitesh asked me to do WBC scan test. The WBC scan was very carefully done under the supervision of Dr. Noaline Sinha, Head, Department of Nuclear Medicine, Artemis Hospital. I must mention the name of Mr. Anil Kumar, the technical personnel who put extra care to get accurate test result, the type of carefulness would hardly be found in our hospitals. The WBC scan did not find any infection in the body.
Unfortunately, the pain is still persisting and the treatment is on. In fact, the actual reason of her pain is yet to be revealed…..till then, this pain, according to medical term may be defined as “Idiopathic Pain”—the pain of unknown origin but the pain is very real!
(M Zahidul Haque is Professor in the Department of Agricultural Extension & Information System, Sher-e-Bangla Agricultural University, Dhaka, Bangladesh. E-mail: prof_haque@hotmail.com)

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